Você está na página 1de 9

166 ORIGINAL ARTICLE

Kenia Machado Souza Freire1,


Nilzete Liberato Bresolin2, Ana
Acute kidney injury in children: incidence and
Camila Flores Farah3, Francisca prognostic factors in critically ill patients
Lígia Cirilo Carvalho3, José Eduardo
Coutinho Góes3
Lesão renal aguda em crianças: incidência e fatores prognósticos
em pacientes gravemente enfermos

1. Pediatric Intensive Care Resident ABSTRACT Gusmão - Florianópolis / SC – Brazil


Physician of Hospital Infantil Joana de was conducted between July 2008 and
Gusmão – Florianópolis (SC), Brazil. Objectives: Acute kidney injury is January 2009. Were evaluated daily the
2. Assistant Professor of Pediatric characterized by sudden and generally urine output and serum creatinine, and
Nephrology for the Universidade revertible renal function impairment the patients were categorized according
Federal de Santa Catarina - UFSC - involving inability to maintain home­ to the pRIFLE criteria.
Florianópolis (SC), Brazil; Physician ostasis. In pediatrics, the main causes Results: During the follow-up pe-
of the Pediatric Intensive Care Unit of of acute kidney injury are sepsis, use of riod, 235 children were admitted. The
Hospital Infantil Joana de Gusmão - nephrotoxic drugs and renal ischemia incidence of acute kidney injury was
Florianópolis (SC), Brazil. in critically ill patients. The incidence 30.6%, and the maximal pRIFLE score
3. Physician of the Intensive Care Unit of acute kidney injury in these patients during hospitalization was 12.1% for R,
of Hospital Infantil Joana de Gusmão - ranges from 20 to 30%, resulting in in- 12.1% for I and 6.4% for F. The mor-
Florianópolis (SC), Brazil. creased morbid-mortality, a 40 to 90% tality rate was 12.3%. The patients who
rate. This study aimed to evaluate the developed acute kidney injury had a ten
incidence of acute kidney injury in in- times bigger risk of death versus the not
tensive care unit patients, to categorize exposed patients.
the severity of the acute kidney injury Conclusions: Acute kidney injury
according to the Pediatric Risk, Injury, is frequent in critically ill patients. Early
Failure, Loss, End-Stage (pRIFLE), diagnosis and prompt and appropri-
examine the relationship between the ate therapy for each clinical aspect may
Work developed at the Hospital Infantil acute kidney injury and severity using change this condition’s course and sever-
Joana de Gusmão - Florianópolis (SC), the Pediatric Index of Mortality (PIM) ity, and reduce the patients’ morbidity
Brazil. [Course Completion Monograph and to analyze outcome predictors. and mortality.
presented to the Intensive Medicine Methods: A prospective study of
Association, Florianópolis (SC), the patients admitted to the intensive Keywords: Child; kidney/injuries; Mor-
Brazil, for certification in the Pediatric care unit of Hospital Infantil Joana de tality; Critical illness
Intensive Care Medicine Residency
Program. Florianópolis (SC), Brazil.
(2009)].

Submitted on February 26, 2010 INTRODUCTION


Accepted on May 23, 2010
Acute kidney injury (AKI) is characterized by a sudden and generally
Author for correspondence: revertible renal function impairment, involving inability to maintain the
Kenia Machado Souza Freire homeostasis, and may or not be accompanied by reduced diuresis.(1-5)
Rua Lourenço Vanucci, 47 - Jardim Usually, AKI may be categorized as pre-renal, related to reduced re-
Guarujá nal blood flow (RBF) for inappropriate cardiac output or intravascular
Zip Code: 18050-606 – Sorocaba (SP),
volume; intrinsic renal disease, from an insult to the renal parenchyma
Brazil.
including ischemic, vascular, tubular or glomerular disorders; and post-
Phone: +55 (15) 3221-1386
E-mail: keniafreire@yahoo.com.br
renal, due to urinary tract obstruction either in single kidney or both
kidneys.(1,3,4,6)

Rev Bras Ter Intensiva. 2010; 22(2):166-174


Acute kidney injury in children 167

During the childhood, the main AKI causes are early AKI detection are currently under investigation,
sepsis, nephrotoxic drugs, and renal ischemia in criti- among them neutrophil gelatinase associated lipocalin
cally ill patients.(1,6) (NGAL), cystatin C, interleukin 18, and kidney injury
These patients, particularly those staying in in- molecule-1 (KIM-1). (20) Although these markers have
tensive care units (ICUs), are exposed to a number good sensitivity and specificity, they are not routinely
of conditions which may result in renal impairment, used due to their low availability and high costs.(19,20)
thus significantly increasing the morbi-mortality In this context, the Acute Dialysis Quality Initiative
rate. (5,7-10) Among the main causes we should men- (ADQI), which involves the participation of nephrolo-
tion: hypovolemia leading to hypoperfusion and gists and intensivists, held in 2002 in the city of Vi-
consequent hypoxia; inflammatory and thrombotic cenza the Second International Consensus Conference
events caused by sepsis; systemic inflammation from of the ADQI.(21) where adult AKI diagnosis criteria were
trauma, major surgeries, extracorporeal circulation; proposed and decided, and detailed published in 2004
use of vasodilator drugs such as phosphodiesterase with the name RIFLE criteria. These are currently un-
inhibitors, sedatives, epidural blockade; vasopres- der scientific community evaluation.(22)
sors; and use of nephrotoxic drugs as aminoglyco- The RIFLE criteria define three grades of increas-
sides, amphotericin B, radiological contrasts, and ing AKI severity (R – Risk of renal dysfunction; I –
drugs interfering with the renal hemodynamics such Injury of the kidney; F – Failure of kidney function)
as angiotensin converting enzyme inhibitors and an- and two outcome variables (L - Loss of kidney func-
giotensin II receptor blockers. (2,4,11,12) tion and E - End-stage kidney disease). For the first
Sepsis, and specially the septic shock, is one of the three categories, the RIFLE criteria aimed to standard-
main causes of AKI. AKI prevalence is sepsis ranges ize AKI definition by patients’ stratification according
from 9% to 40%, involves poor prognosis, and is as- to serum creatinine and urinary output changes from
sociated with a 70% mortality rate.(2,13,14) baseline. Loss of kidney function and End-stage kid-
Among critically ill renal impaired patients, about ney disease define two categories based on the RRS
6% may need renal replacement therapy (RRT), with time required after the initial insult.(21)
a mortality rate increased by 50 to 80%, particularly Recently, Akcan-Arikan et al. provided a pediatric
associated with sepsis, septic shock, and multiple or- patients-modified RIFLE version (pRIFLE), based on
gan and systems dysfunction (MODS).(6,15,16) a 12 months single center study where 150 critically ill
Considering the close association between severely children were prospectively analyzed. (23) The proposed
ill patients and AKI, the quantification of ICU pa- pRIFLE criteria are based on the estimated creatinine
tient’s severity is mandatory. In pediatrics, the most clearance (ECC) calculated by means of the Schwartz
used prognostic indicators are PRISM (Pediatric Risk formula(24) or on the urinary output reduction, in a
Index Score for Mortality) and PIM (Pediatric Index body weight per hour basis, as detailed on Table 1.
of Mortality).(17,18) This study aimed to evaluate the incidence of AKI
The AKI diagnosis methods include: clinical evalu- in ICU patients, and to categorize the AKI severity
ation of the urinary output and laboratory tests as uri- according to the new pRIFLE diagnosis criteria, quan-
nalysis, blood urea nitrogen, and creatinine, however tify and analyze the AKI and PIM-evaluated severity,
with low sensitivity and specificity.(19) Biomarkers for and to evaluate the associated prognostic factors.

Table 1 – RIFLE criteria modified for children


Estimated creatinine clearance (ECC) Urinary output
Risk of kidney injury ECC reduction by 25% < 0.5 mL/kg/h for 8 hours
Renal injury ECC reduction by 50% < 0.5 mL/kg/h for 16 hours
Renal function failure ECC reduced by 75% or ECC < 0.3 mL/kg/h for 2 hours
< 35 mL/min/1.73m2 or anuria for 12 hours
Loss of kidney function Persistent renal function failure > 4 weeks
End-stage renal disease Persistent renal function failure > 3 months
Source: Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL. Modified RIFLE criteria in critically ill children with
acute kidney injury. Kidney Int. 2007;71:1028-35. RIFLE - risk, injury, failure, loss, end-stage; ECC – estimated creatinine clearance.

Rev Bras Ter Intensiva. 2010; 22(2):166-174


168 Freire KMS, Bresolin NL, Farah ACF,
Carvalho FLC, Góes JEC

METHODS For kidney injury degree (pRIFLE) (23) categoriza-


tion, were analyzed daily: urinary output and serum
A prospective study was conducted from July 2008 creatinine level, and the estimated creatinine clear-
to January 2009 which included all patients admit- ance was calculated according to the Schwartz for-
ted to the pediatric intensive care unit (PICU) of the mula.(24) The patients admitted with missing baseline
Hospital Infantil Joana de Gusmão (HIJG) – Flori- renal function data had the normal clearance value of
anópolis (SC) - Brazil. This is an eight beds pediatric 100 mL/1.73 m 2/24 h considered as reference, as pro-
ICU, of tertiary degree of complexity, and receives posed by Akcan-Arikan et al.(23)
both clinical and surgical patients. The data collected were statistically analyzed. The
This study was approved by the Institution’s Eth- quantitative variables were expressed as means and
ics Committee (registration number 041/2008). This standard deviations, lower, higher and median values.
study was explained to the patients’ parents or legal The categorical variables were described by their abso-
representatives, before they were asked to sign the In- lute (n) and relative (%) frequencies. The association
formed Consent Form. between the different variables was analyzed by appro-
The inclusion criteria were: patients older than priate hypothesis testing (Pearson’s Chi-square, exact
29 days and younger than 16 years, and time of stay Fisher’s, Mann-Whitney’s, and Kruskall-Wallis tests).
above 24 hours. Patients with previous renal disease The relative risks (RR) for patients’ gender, different
were excluded. diagnosis, outcomes for either with or without acute
The included patients were followed during their renal failure were calculated, as well as their respective
stay in the PICU, and their data were collected daily 95% Confidence Intervals (95%CI). P values ≤ 0.05
according to the approved protocol. The patients were were considered significant.(25) The analysis were per-
categorized according to their age, gender, mortality formed using the MS Excel and EpiInfo 6.04 softwares.
risk rate prognosis by admission (using the PIM II
prognosis score)(18); admission diagnosis, degree of RESULTS
kidney injury (pRIFLE) during the hospitalization,
mechanic ventilation (MV) need, vasoactive drugs During this six months period 245 children were
(VD) need, nephrotoxic drugs (ND) exposure, perito- admitted to the PICU, being ten of them excluded
neal dialysis (PD) need, time of stay in days (HD) and for chronic renal failure. Of the 235 children in this
outcome (either discharge or death). study, 48.9% were male (Table 2).

Table 2 – Profile of patients admitted to the intensive care unit


Kidney injury
Variables No Yes Total RR 95%CI P value
N (%) N (%)
Gender
Male 80 (68.4) 37 (31.6) 117 1.00
Female 86 (72.9) 32 (27.1) 118 0.86 0.58-1.28 0.4480
Diagnosis
Resp.Fail. 32 (74.4) 11 (25.6) 43 0.83 0.44-1.54 0.5600
SIRS/sepsis 16 (39.0) 25 (61.0) 41 3.76 2.14-6.59 <0.0010
HT/Trauma 30 (88.2) 4 (11.8) 34 0.32 0.12-0.88 0.0150
General PS 48 (90.6) 5 (9.4) 53 0.25 0.10-0.60 <0.0010
Heart PS 12 (41.4) 17 (58.6) 29 3.41 1.72-6.75 <0.0010
Others 28 (80.0) 7 (20.0) 35 0.60 0.28-1.31 0.1870
Outcome
Discharge 154 (74.8) 52 (25.2) 206 1.00
Death 12 (41.4) 17 (58.6) 29 10.43 5.95-18.28 <0.0001
Total 166 69 235
RR – relative risk; CI – confidence interval; Resp.Fail. – respiratory failure; SIRS – systemic inflammatory response syndrome; HT - head trauma;
PS –post surgery. Pearson’s Chi-square test.

Rev Bras Ter Intensiva. 2010; 22(2):166-174


Acute kidney injury in children 169

Post-operative patients constituted 34.9% of 24.6%), 70.6% (12/17) remained in this level,
the sample (Table 2). Patients admitted for pri- 23.5% (4/17) progressed to I, and 5.9% (1/17)
mary heart, neurological or hematological disease progressed to F. Differently, of the 5.8% (4/69)
were categorized under “other” diagnosis. patients admitted with level I, no one had AKI
Of the 235 patients, 69 (30.6%) had some de- level progression, as well as 5.8% (4/69) of the
gree of AKI, being the maximal pRIFLE value admitted with AKI level F.
during their hospitalization 12.1% for Risk (R),
12.1% for Injury (I) and 6.4% for Failure of the
renal function (F) (Figure 1). Regarding the diag-
nosis, patients admitted due to Systemic Inflamma-
tory Response Syndrome (SIRS)/Sepsis and heart
surgery post-operative period had a three fold risk
of developing AKI (RR 3.76 95%CI 2.14-6.59 and
RR 3.41 95%CI 1.72-6.75, respectively), while pa-
tients admitted for respiratory failure and “other”
had no statistically significant difference (Table 2).

ICU – intensive care unit; AKI – acute kidney injury.


Figure 2 – Distribution of the patients admitted to
the intensive care unit according to the maximal
kidney injury progress during the time of stay.

Of the patients with any level AKI, 53.6% were


AKI – acute kidney injury
male, with an average age of 34 months, median
Figure 1 – Distribution of the patients admitted to 11 months, and standard deviation of 47%, and
the intensive care unity according to their maximal no statistically significant difference was identi-
level of acute kidney injury during the time of stay. fied for AKI (Table 3). The time of stay ranged
from one day to 58 days, average 9 days, median
4 days, and standard deviation 11.7%. The pa-
Twenty nine (12.3%) of the 235 admitted tients were categorized according to the time of
patients died, and those with AKI had a risk of stay in ≤ 7 days and > 7 days, as in the Akcan-
death ten times bigger versus the non-exposed Arikan et. al. (23) article. The patients who stayed
(RR 10.43 95%CI 5.95-18.28) (Table 2). longer (more than seven days), had more severe
Of the 69 AKI patients, 37 (53.6%) were male. AKI (I and F) (p = 0.019) (Table 3).
Infants were the predominant age range (44; 63.8%). The patients’ mortality rate was evaluated us-
The vast majority (46; 66.7%) stayed shorter than ing the PIM II prognosis score. The mortality rate
seven days. Only eight (11.6%) patients needed ranged between 0.1% and 100%, average 25%, me-
RRT. Seventeen patients (24.6%) died. dian 2.9%, standard deviation 36.5%, and patients
Among the AKI patients, the maximal pRIFLE with higher PIM levels (above 10%) were observed
score identified during the stay was 39.1% R, to have more severe AKI (p = 0.026) (Table 3).
39.1% I and 21.8% F (Table 1). Regarding the PICU admission diagnosis,
Figure 2 shows that by the ICU admission, those admitted for respiratory failure, SIRS/sep-
63.8% (44/69) of the patients had no AKI, which sis and after heart surgery had increased AKI se-
was diagnosed in variable degrees, being 34.1% verity (p = 0.047) (Table 3).
(15/44) R, 43.2% (19/44) I, and 22.7% (10/44) Regarding mechanic ventilation or vasoactive drugs
F. Of the patients admitted with AKI R (17/69; requirement, and exposure to nephrotoxic drugs, the

Rev Bras Ter Intensiva. 2010; 22(2):166-174


170 Freire KMS, Bresolin NL, Farah ACF,
Carvalho FLC, Góes JEC

exposed patients had increased renal injury (p = 0.03, needed RRT.


0.001 and 0.002, respectively) (Table 3). Regarding the outcome, the patients who died
Patients requiring RRT also had more severe had more severe renal injury versus those who were
AKI (p = 0) (Table 3). This is confirmed in figure discharged (p = 0.002) (Table 3). In Figure 3 it is
3, showing that 40% of the level F AKI patients shown that 60% of the level F AKI patients died.

Table 3 – Profile of patients admitted to the intensive care unit who developed acute kidney injury and their prognostic factors
Kidney injury level Risk Injury Failure P value Total
N (%) N (%) N (%)
Variables
Gender 0.554
Male 15 (40.5) 16 (43.3) 6 (16.2) 37
Female 12 (37.5) 11 (34.4) 9 (28.1) 32
Age range 0.222
Infant 16 (36.4) 21 (47.7) 7 (15.9) 44
Preschool 8 (50.0) 3 (18.7) 5 (31.3) 16
School/Adolescent 3 (33.3) 3 (33.3) 3 (33.3) 9
Time of Stay 0.019
≤7 23 (50.0) 16 (34.8) 7 (15.2) 46
>7 4 (17.4) 11 (47.8) 8 (34.8) 23
PIM (%)
≤ 10 18 (47.4) 15 (39.5) 5 (13.1) 38
> 10 8 (32.0) 7 (28.0) 10 (40.0) 25
Not done 1 (16.7) 5 (83.3) 0 (0.0) 6
Diagnosis 0.047
Respiratory failure 4 (36.3) 4 (36.3) 3 (27.3) 11
SIRS/Sepsis 7 (28.0) 8 (32.0) 10 (40.0) 25
HT/Trauma 2 (50.0) 1 (25.0) 1 (25.0) 4
Heart PS 5 (29.4) 11 (64.7) 1 (58.9) 2
General PS 3 (60.0) 2 (40.0) 0 (0.0) 17
Others 6 (85.7) 1 (14.3) 0 (0.0) 7
MV 0.030*
Yes 13 (28.9) 19 (42.2) 13 (28.9) 45
No 14 (58.3) 8 (33.3) 2 (8.3) 24
Vasoactive drugs 0.001*
Yes 13 (27) 20 (41.7) 15 (31.3) 45
No 14 (66.7) 7 (33.3) 0 (0) 24
Nephrotoxic drugs 0.002*
Yes 10 (23.3) 20 (46.5) 13 (30.2) 43
No 17 (65.4) 7 (26.9) 2 (7.7) 26
Peritoneal dialysis 0*
Yes 0 (0.0) 2 (25.0) 6 (75.0) 8
No 27 (44.3) 25 (41.0) 9 (14.7) 61
Outcome 0.002**
Discharge 23 (44.2) 23 (44.2) 6 (11.6) 52
Death 4 (23.5) 4 (23.5) 9 (53) 17
Total 27 27 15 69
*Fisher’s exact test; ** Pearson’s Chi-square test. PIM - pediatric index of mortality; SIRS – systemic inflammatory response syndrome; HT – head
trauma; PS – post-surgery; MV –mechanic ventilation

Rev Bras Ter Intensiva. 2010; 22(2):166-174


Acute kidney injury in children 171

45% of the patients were diagnosed AKI in their


first 24 hours. Akcan-Arikan et al. (23) identified
AKI in 42.3% of their sample. These data empha-
size the sensitivity of the pRIFLE criteria for di-
agnosis AKI.
Aiming to evaluate if more severe patients had
increased AKI sensitivity versus less severe patients,
the PIM II score was calculated. The isolated as-
sociation between the PIM II and AKI identified
higher means and medians for the exposed group,
as anticipated by the authors. Similarly, this same
AKI – acute kidney injury; PD – peritoneal dialysis. association was found by Akcan-Arikan et al. (23)
Figure 3 – Distribution of the patients admitted to the inten- Conversely, Plötz et al. (16) in 2005, studying sep-
sive care unit according to the maximal level of acute kidney tic patients, identified no difference between the
injury during the time of stay versus death rate and renal prognostic scores in patients who either developed
replacement therapy need. or not AKI. In adults, the association of prognos-
tic scores and AKI was clearly shown in the Bag-
shaw et al. (9) and Hoste et al. (22) studies.
DISCUSSION The studies using the RIFLE criteria, both in
adults and children, validated a positive statisti-
AKI has a known catastrophic impact on criti- cally significant association between time of stay,
cally ill patients. It is common among them, and both in the ICU or hospital, and AKI, proving a
its cause is mostly multifactor. AKI may progress poorer prognosis predictor in critically ill patients.
to renal failure, preventing the kidneys to play In this cohort we observed that the mean ICU stay
their most important role, homeostasis. time increased as the AKI severity progressed. Dif-
During the study were admitted to the PICU ferently, Plötz et al. (26) showed no statistically sig-
245 patients, 235 complied with the inclusion nificant differences between the control and AKI
criteria, and among them, the AKI incidence was groups regarding the ICU time of stay. Akcan-Ari-
30.6% (69 patients). Ostermann and Chang (5) kan et al. (23) not only showed a trend in the exposed
studied adult patients from the United Kingdom group to stay longer in the ICU, but also observed
and Germany, and found a 35.8% incidence, while that AKI was an independent factor for increased
Host et al. (22) found a 67.2% incidence and in a hospital stay risk. Similarly, in studies with adult
multicenter study, and Bagshaw et al. (9) found an patients using the RIFLE criteria, Hoste et al. (22)
36.1% incidence. Among children Akcan-Arikan and Ostermann and Chang (5) identified the same
et al. (23) found an 82% incidence, while Plötz et associations for ICU time of stay.
al. (26) found 58%. Regarding mortality, several studies (5,7,9,16,19,22,26)
Regarding the AKI level, the maximal RIFLE have clearly shown that any degree of AKI is a poor
score found during the patients stay was 39.1% R, prognosis indicator for critically ill patients. In
39.1% I and 21.8 F, while Akcan-Arikan et al. (23) this sample, we found that the in-hospital mortal-
found 48.8%, 26% and 25.2%, respectively, and ity of patients with the condition was ten times
Plötz et al. (26) 52%, 37% and 11%, respectively. bigger than in the group with no AKI, accord-
The variable AKI incidences could be explained ing to the pRIFLE. Plötz et al. (26) identified a five
by the different populations studied, and also by times bigger mortality in patients with any level
the different ICU characteristics. Specially regard- AKI. Akcan-Arikan et al. (23) found no statistically
ing pediatric studies with all patients under MV, significant difference for both groups mortality. In
while in this study only 65.2% needed ventilatory adults, Hoste et al. (22) identified three times big-
support. ger mortality rates in the exposed group. Oster-
Of the 69 patients who developed AKI at any mann and Chang (5) identified that AKI patients
time of their stay, 36.2% were diagnosed AKI in had a four times bigger mortality versus non-AKI
the first day. Similarly, in the Plötz et al. (26) study, patients.

Rev Bras Ter Intensiva. 2010; 22(2):166-174


172 Freire KMS, Bresolin NL, Farah ACF,
Carvalho FLC, Góes JEC

Regarding the mortality rates, we found that In the studied group, RRT was required by
mortality increased in parallel with the AKI se- 11.6% patients. In the Host et al. (22) study, this
verity groups, which was also identified by other rate was 5.9%, and in the Akcan-Arikan et al. (23)
authors. (22,23) A similar mortality rate was found 8.9% of the patients needed RRT, while in the
for AKI R and I levels (14.8%). The identification study by Plötz et al. (26) , 10%. In all of these stud-
that the level R has increased progression to more ies, the need of RRS was proportional to the AKI
severe levels, and high mortality rates in this level severity. Among the patients with any AKI level,
similar to level I (more severe), emphasize the rel- eight underwent RRT. The vast majority of them
evance of the early diagnosis and therapy. It is thus were in the F level, representing 40% (6/15) of
suggested that early AKI diagnosis will result in this subgroup. Akcan-Arikan et al. (23) found that
improved prognosis and, specially, reduced mor- 71% of the F level patients received RRT, and for
tality. Yet patients categorized as level F had a sub- Plötz et al. (26) this involved 14.3% of the patients.
stantially higher mortality rate (60%) versus other The different RRT indication in these three stud-
AKI levels, showing that the level F represents a ies may be related to a lack of specific criteria for
severe insult condition, with severe functional im- RRT indication and probably due to different
pairment and decreased reversibility, nevertheless population characteristics, although all were criti-
the best of the therapeutic efforts. cally ill patients.
Regarding the admission diagnosis, patients This study contribution has limitations. Firstly,
with SIRS/sepsis had a three times bigger AKI a relatively small sample size with 235 patients,
risk (p<0.001). Akcan-Arikan et al. (23) and Plötz which however is in similar to other recent stud-
et al. (26) alto identified increased AKI incidence in ies’ samples in pediatrics. Secondly, this is a single
these patients. center study, which may cause bias due to specific
Patients admitted after heart surgery had 58.6% environmental characteristics including popula-
renal injury, and most of these patients had more tion, routines and RRT management and indica-
severe renal injury. In a pediatric study, Perdensen tion. Additionally, other biases may be present due
et al. (27) found a 11.5% incidence. Kuitunen et to the heterogeneous distribution of some clini-
al. (28) , evaluating adult patients, found a 19.3% cal features (age, severity scores, MV, VD, ND).
rate, and these patients had less severe renal in- These would be adjusted by a multivariate analysis
jury. This relevant difference may be explained by in a regression test, not performed. However, this
the fact of diagnosis of acute renal failure (ARF) study proposal was based on a census, for which
in the pediatric study was made based on the uri- all patients complying with the inclusion criteria
nary output (anuria or oliguria), hyperkalemia or would constitute a cohort.
volume excess, while in this study the pRIFLE cri- It is important to highlight that, nevertheless
teria allowed earlier AKI diagnosis. This finding the validation of the new AKI criteria, this condi-
demonstrates the pRIFLE criteria sensitivity and tion’s diagnosis is troublesome as it is based in two
applicability. The difference on AKI incidence in functional abnormalities: serum creatinine chang-
adult or pediatric patients following heart surgery es (a GFR marker) and oliguria, both late renal im-
is due to the more complex surgeries for congeni- pairment markers. Creatinine level may not change
tal defects corrections. Alkan et al. (29) describe that until 25-50% of the renal function is lost. Addi-
younger patients, more complex cardiac defects, tionally, different analysis methods (Jaffé versus
longer extracorporeal circulation, and lower heart enzymatic) may lead to different serum creatinine
output are risk factors for AKI. In this context, values, and drugs leading to tubular creatinine se-
they propose using a prophylactic PD catheter in cretion and increased bilirubin levels may impact
newborns or infants undergoing complex heart the measurements by the Jaffé technique; and, in
surgery. Regarding prognostic factors for AKI de- lower GFR conditions, the creatinine concentra-
velopment as mechanic ventilation, nephrotoxic tion may overestimate the renal function. The dis-
drugs and vasoactive amines need, it was shown tribution volume, commonly changed in critically
that in the exposed group the AKI incidence was ill patients, may also impact the results, as does
higher. These results were also reproduced in adult the patient’s liver metabolism and body mass. For
patients studies. (5,7,8) diuresis measurement, several limitations may be

Rev Bras Ter Intensiva. 2010; 22(2):166-174


Acute kidney injury in children 173

commented. Its accuracy depends on catheteriza- RESUMO


tion, and the values may be changed by several
drugs, specially diuretics and vasoactive amines. Objetivos: Lesão renal aguda caracteriza-se pela
On the other hand, we understand that this redução súbita e, em geral, reversível da função renal
study is useful for pRIFLE criteria validation, and com perda da capacidade de manutenção da homeostase
as it was prospectively used, allows to clearly show do organismo. Em pediatria, as principais causas de
lesão renal aguda são sepse, uso de drogas nefrotóxi-
the accuracy and reliability of the described as-
cas e isquemia renal nos pacientes criticamente enfer-
sociations. Additionally, its contribution to dem-
mos. Nesses pacientes, a incidência de lesão renal aguda
onstrate its use in the intensive care settings, espe- varia de 20 a 30%, resultando em aumento da taxa de
cially for prevention, is undeniable. morbi-mortalidade de 40 a 90%. Este estudo tem como
Looking to future scientific progress, we believe objetivo avaliar a incidência de lesão renal aguda nos
that although pRIFLE in pediatrics publications pacientes internados em unidade de terapia intensiva,
are steadily growing, the articles are relatively classificar a gravidade da lesão renal aguda de acordo
scarce and conducted in single centers. An impor- com o Pediatric Risk, Injury, Failure, Loss, End-Stage
tant step forward to widespread the acceptance of (pRIFLE), analisar a relação entre lesão renal aguda e a
the pRIFLE criteria would involve conducting a gravidade através do Pediatric Index of Mortality (PIM)
larger and multicenter study. e estudar os fatores prognósticos associados.
Métodos: Realizou-se um estudo prospectivo entre
CONCLUSION julho de 2008 a janeiro de 2009 dos pacientes interna-
dos na unidade de terapia intensiva pediátrica do Hos-
In this study the incidence of AKI in critically pital Infantil Joana de Gusmão – Florianópolis (SC) -
Brasil. Todos os pacientes foram analisados diariamente
ill patients was high. AKI was directly related to
através do débito urinário e creatinina sérica e classifi-
increased mortality, with a ten times bigger risk of
cados de acordo com pRIFLE.
death versus patients without AKI. Resultados: No período de acompanhamento foram
Regarding the applicability of the pRIFLE cri- internadas 235 crianças. A incidência de lesão renal
teria as a prognostic tool in ICU, the most severe aguda foi de 30,6%, sendo que o pRIFLE máximo du-
AKI patients had a higher PIM II prognostic score. rante a internação foi de 12,1% para R, 12,1% para I
The time of hospital stay was determinant. It e 6,4% para F. A taxa de mortalidade foi de 12,3%. Os
was seen that patients staying longer had more se- pacientes que evoluíram com lesão renal aguda apresen-
vere AKI. Regarding the AKI-associated prognos- taram risco dez vezes maior de óbito em relação aos não
tic factors, it was identified that MV and VD need expostos.
and exposure to ND lead to more severe AKI, and Conclusão: Lesão renal aguda é uma entidade co-
PD was required more frequently in the patients mum nos pacientes críticos. O diagnóstico precoce a e
with more severe AKI. instituição imediata de medidas terapêuticas adequadas
The pRIFLE criteria were shown to be impor- a cada situação clínica podem alterar o curso e a gravi-
tant for early AKI risk patients detection, suggest- dade do envolvimento renal reduzindo a morbi-mortal-
idade do paciente.
ing that, with its use, earlier diagnosis will imply
more careful and less delayed therapy, which in
Descritores: Criança; Rim/lesões; Mortalidade; Es-
long term will lead to reduction in this disease re- tado terminal
lated morbidity and mortality.

REFERENCES 4. Fine DM. Acute renal failure in the critically ill. Multipro-
fessional Crit Care Review Course, 2005.
1. Andreoli SP. Acute kidney injury in children. Pediatr Ne- 5. Ostermann M, Chang RW. Acute kidney injury in the
phrol. 2009;24(2):253-63. intensive care unit according RIFLE. Crit Care Med.
2. Liberato Bresolin N, Toporovski J. Insuficiência renal aguda 2007;35(8):1837-43; quiz 1852.
na sepse. Arch Latinoam Nefrol Pediatr. 2005;5(3):164-72. 6. Zappitelli M. Epidemiology and diagnosis of acute kidney
3. Costa JAC, Vieira-Neto OM, Moysés Neto M. Insuficiência injury. Semin Nephrol. 2008;28(5):436-46.
renal aguda. Medicina (Ribeirão Preto). 2003;36(2/4):307-24. 7. Barrantes F, Tian J, Vazquez R, Amoateng-Adjepong

Rev Bras Ter Intensiva. 2010; 22(2):166-174


174 Freire KMS, Bresolin NL, Farah ACF,
Carvalho FLC, Góes JEC

Y, Manthous CA. Acute kidney injury criteria pre- V, Góes J, Carvalho FL. Prognosis for children with acu-
dict outcomes of critically ill patients. Crit Care Med. te kidney injury in intensive care unit. Pediatr Nephrol.
2008;36(5):1397-403. 2009;24(3):537-44.
8. Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu 20. Nguyen MT, Devarajan P. Biomarkers for the early de-
H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, tection of acute kidney injury. Pediatr Nephrol. 2008;
Gibney N, Tolwani A, Ronco C; Beginning and Ending 23(12):2151-7.
Supportive Therapy for the Kidney (BEST Kidney) Inves- 21. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P;
tigators. Acute renal failure in critically ill patients: a mul- Acute Dialysis Quality Initiative workgroup. Acute renal
tinational, multicenter study. JAMA. 2005;294(7):813-8. failure – definition, outcome measures, animal models,
9. Bagshaw SM, George C, Dinu I, Bellomo R. A multi-cen- fluid therapy and information technology needs: the Se-
tre evaluation of the RIFLE criteria for early acute kidney cond International Consensus Conference of the Acu-
injury in critically ill patients. Nephrol Dial Transplant. te Dialysis Quality Initiative (ADQI) Group. Crit Care.
2008;23(4):1203-10. 2004;8(4):R204-12.
10. Liberato Bresolin N, Santos Bandeira MF, Toporovski J. 22. Hoste EA, Clermont G, Kersten A, Venkataraman R, An-
Monitorização da função renal na insuficiência renal agu- gus DC, De Bacquer D, Kellum JA. RIFLE criteria for
da. Arch Latinoam Nefrol Pediatr. 2007;7(1):20-34. acute kidney injury are associated with hospital morta-
11. Pannu N, Nadim MK. An overview of drug-induced acute lity in critically ill patients: a cohort analysis. Crit Care.
kidney injury. Crit Care Med. 2008;36(4 Suppl):S216-23. 2006;10(3):R73.
Review. 23. Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK,
12. Bellomo R, Wan L, May C. Vasoactive drugs and acute Jefferson LS, Goldstein SL. Modified RIFLE criteria in
kidney injury. Crit Care Med. 2008;34(4 Suppl):S179-86. critically ill children with acute kidney injury. Kidney Int.
Review. 2007;71(10):1028-35.
13. Schrier RW, Wang W. Acute renal failure and sepsis. N Eng 24. Schwartz GJ, Brion LP, Spitzer A. The use of plasma creati-
J Med. 2004;351(2):159-69. Review. nine concentration for estimating glomerular filtration rate
14. Schor N. Acute renal failure and the sepsis syndrome. Kid- in infants, children, and adolescents. Pediatr Clin North
ney Int. 2002;61(2):764-76. Am. 1987;34(3):571-90.
15. VA/NIH Acute Renal Failure Trial Network, Palevsky 25. Kirkwood B. Essentials of medical statistics. Oxford: Bla-
PM, Zhang JH, O’Connor TZ, Chertow GM, Crow- ckwell; 1988.
ley ST, Choudhury D, el al. Intensity of renal support 26. Plötz FB, Bouma AB, van Wijk JA, Kneyber MC,
in critically ill patients with acute kidney injury. N Eng Bökenkamp A. Pediatric acute kidney injury in the ICU:
J Med. 2008;359(1):7-20. Erratum in: N Engl J Med. an independent evaluation of pRIFLE criteria. Intensive
2009;361(24):2391. Care Med. 2008;34(9):1713-7.
16. Plötz FB, Hulst HE, Twisk JW, Bökenkamp A, Markhorst 27. Pedersen KR, Hjortdal VE, Christensen S, Pedersen J,
DG, van Wijk JA. Effect of acute renal failure on outco- Hjortholm K, Larsen SH, Povlsen JV. Clinical outcome
me in children with severe septic shock. Pediatr Nephrol. in children with acute renal failure treated with peritoneal
2005;20(8):1177-81. dialysis after surgery for congenital heart disease. Kidney
17. Pollack MD, Patel KM, Ruttimann UE. PRISM III: an Int Suppl. 2008;(108):S81-6.
updated Pediatric Risk of Mortality score. Crit Care Med. 28. Kuitunen A, Vento A, Suojaranta-Ylinen R, Pettilä V. Acu-
1996;24(5):743-52. te renal failure after cardiac surgery: evaluation of the RI-
18. Slater A, Shann F, Pearson G; Paediatric Index of Mor- FLE classification. Ann Thorac Surg. 2006;81(2):542-6.
tality (PIM) Study Group. PIM2: a revised version of 29. Alkan T, Akçevin A, Türkoglu H, Paker T, Sasmazel A,
the Paediatric Index of Mortality. Intensive Care Med. Bayer V, el al. Postoperative prophylactic peritoneal dialy-
2003;29(2):278-85. sis in neonates and infants after complex congenital cardiac
19. Bresolin N, Silva C, Halllal A, Toporovski J, Fernandes surgery. ASAIO J. 2006;52(6):693-7.

Rev Bras Ter Intensiva. 2010; 22(2):166-174